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Research Subject
Informed Consent Form
Title of Study:
Insert Title of Research Study
Inset Study Number
Principal
Investigator:
Name of the Principal Investigator
Department of Principal Investigator
Applicable NYU School or College
Address
Phone Numbers
Emergency
Contact:
Insert Emergency Contact
Insert Phone Number/Pager, etc.
1. About volunteering for this research study
You are being invited to take part in a research study. Your participation is voluntary which means you
can choose whether or not you want to take part in this study.
People who agree to take part in research studies are called “subjects” or “research subjects”. These
words are used throughout this consent form. Before you can make your decision, you will need to know
what the study is about, the possible risks and benefits of being in this study, and what you will have to
do in this study. You may also decide to discuss this study and this form with your family, friends, or
doctor. If you have any questions about the study or about this form, please ask us. If you decide to take
part in this study, you must sign this form. We will give you a copy of this form signed by you for you to
keep.
[NOTE TO RESEARCHERS:
 Reference is made to the NYU Langone Medical Center. For NYU researchers outside of the School
of Medicine, make sure you replace School of Medicine text with the applicable NYU School or
College and change the NYU logo above as appropriate.
 For various sections below that do not include standardized language text, see the companion
document: Example Language for Non -Biomedical Informed Consent Form]
 All text in italics must be deleted from this document before submitting to the IRB
2. What is the purpose of this study?
Provide a concise explanation of the purpose of the research.
3. How long will I be in the study? How many other people will be in the
study?
Provide expected duration of a subject’s involvement with the study
Provide expected total duration of study.
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Provide the expected total number of subjects in study.
(optional) Include number of subjects at NYULMC.
4. What will I be asked to do in the study?
Provide a high level overview of the major elements of the study and what is expected of the subject
(i.e. note here only the major procedures and milestones).
After the general overview, list each study visit separately and identify by visit number/name. Include
for each visit:
 The amount of time the subject will be at the visit
 Activities and procedures to be conducted during the visit
 Any other relevant information pertaining to that individual study visit.
Describe each test/procedure in layman’s terms.
Clearly identify which procedures are experimental.
(optional) May be complimented by a simple table or chart or other additional materials may be
inserted here or given as a handout. Any such materials require IRB approval.
5. What are the possible risks or discomforts?
Risk of Study
Describe the known risks from the study including reference to frequency & severity.
Unforeseeable Risks: Include a statement that the research may involve risks that are currently
unforeseeable.
Other Risks
Describe the risks, discomforts/inconveniences of study-related procedures that were noted in the
section “What am I being asked to do?” If standard of care testing is being changed, describe any
resultant risk, if applicable.
If appropriate, include description of relating to privacy and/or confidentiality concerns. (e.g., genetic
testing and GINA).
6. What if new information becomes available?
During the course of this study we may find more information that could be important to you. This
includes information that might cause you to change your mind about being in the study. We will notify
you as soon as possible if such information becomes available.
7. What are the possible benefits of the study?
If direct subject benefits can reasonably be anticipated as a result of participating in the study, then
describe such possible benefits.
If direct subject benefits are NOT anticipated, state so clearly – e.g. “You are not expected to get any
benefit from being in this research study.”
(optional) Describe the anticipated benefits to society.
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8. What other choices do I have if I do not participate?
Provide information on other treatments or options available.
Discuss alternatives to entering the study including.
Include a statement that subjects may discuss alternatives with their personal physician.
9. Will I be paid for being in this study?
Describe any monetary or other kind of compensation (payments/stipend, expenses, free products),
including paying subjects for their time and reimbursing travel or parking.
Provide a break down the total compensation (i.e. clarify if paid after each visit/procedure etc.).
If there is no compensation for participation in this study, state that.
Confirm that the information provided in this section is consistent with the study budget and any
funding agreements.
Consider language if applicable for studies colleting specimens for future use. e.g., “Although future
research that uses your samples may lead to the development of new products, you will not receive
any payments for these new products.”
[Example language if study plans include subject payment:]
You will be paid [per completed visit, procedure, etc.]. If you chose to leave or are withdrawn from the
study for any reason before finishing the entire study, you will be paid for [each completed visit,
procedure, etc.].
If you complete all the study visits, you will receive [dollar amount] for being in this study.
In order for you to receive a payment check, you need to give the study staff either your Social Security
number or your Alien Registration number. If you do not have either of these numbers, you may be in
the study but will not receive any payment.
[Example language if study plans reimburse travel/lodging expenses:]
We will pay you back for travel costs to and from the study site and any hotel costs related to the study.
In order to be paid, you must give the receipts to the study staff.
10. Will I have to pay for anything?
Discuss procedures or tests that are not covered by the study, stating how they will be paid for (e.g.,,
third party payer, etc.).
Confirm that the information provided in this section is consistent with the study budget, funding
agreement.
[For studies where there are plans to charge certain costs to subjects and/or their health insurance:]
You and/or your health insurance may be billed for the costs of medical care during this study if these
expenses would have happened even if you were not in the study, or if your insurance agrees in
advance to pay. If you have health insurance, the cost of these services will be billed to your insurance
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company. If your insurance does not cover these costs or you do not have insurance, these costs will be
your responsibility.
11. What happens if I am injured from being in the study?
For research that poses greater than minimal risks to participants:
Provide contact information for research-related injury (i.e. refer to the contact information noted in
Consent header, if appropriate)
Describe what treatment will be provided for research related injuries.
Explain how treatment for research related injuries would be paid.
Explain Subject’s responsibilities relating to research related injuries.
For medical emergencies contact 911. If you think you have been injured as a result of taking part in this
research study, tell the principal investigator as soon as possible. The principal investigator’s name and
phone number are listed at the top of page 1 of this consent form.
[Example language for non-industry-sponsored research. Modify for consistency with the clinical trial
agreement.]
We will offer you the care needed to treat injuries directly resulting from taking part in this research. We
may bill your insurance company or other third parties, if appropriate, for the costs of the care you get for
the injury, but you may also be responsible for some of them.
[Example language for industry-sponsored research. Modify for consistency with the clinical trial
agreement.]
We will offer you the care needed to treat injuries directly resulting from taking part in this research. The
study sponsor, [insert name of study Sponsor], will pay the costs of the care you get as a direct result of
your participation in the study. If there are costs that the study sponsor does not pay for, we may bill
your insurance company or other third parties, if appropriate, for the costs of the care you get for the
injury, but you may also be responsible for some of them.
[Note: Insert this as last sentence after wording about payment for study-related injury:]
There are no plans for the NYU School of Medicine or Medical Center to pay you or give you other
compensation for the injury. You do not give up your legal rights by signing this form.
[For NCI supported cancer trials, consider including the following information:]
For more information on clinical trials and insurance coverage, you can visit the National Cancer
Institute’s website at: http://cancer.gov/clinicaltrials/understanding/insurance-coverage. Another way to
get this information is to call 1-800-4-CANCER (1-800-422-6237) and ask them to send you a free copy.
12. When is the study over? Can I leave the Study before it ends?
Define when the overall study is to end.
Explain what events could lead to early study closure.
Note that the subject can elect to leave the study at any time without penalty or loss of benefits to
which the subject is otherwise entitled.
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If early withdrawal could expose the subject to medical risks, describe and how those risks will be
minimized or prevented (e.g. in a hypertensive study, it may be necessary to wean a subject off the
study medication or to transition them to alternate therapy).
[Example for drug and device studies:]
This study is expected to end after all participants have completed all visits, and all information has been
collected. This study may also be stopped or your participation ended at any time by your physician, the
or study sponsor without your consent because:
 The principal investigator feels it is necessary for your health or safety. Such an action would not
require your consent, but you will be informed if such a decision is made and the reason for this
decision.
 You have not followed study instructions.
 The study sponsor, the principal investigator or other body responsible for monitoring the safety of
the study has decided to stop the study.
If you decide to participate, you are free to leave the study at anytime. Leaving the study will not
interfere with your future care, payment for your health care or your eligibility for health care benefits.
13. How will my information be protected?
NYU Langone Medical Center, which includes NYU Hospitals Center and NYU School of Medicine, is
committed to protecting the privacy and confidentiality of your health information. We are asking for your
permission to use and to disclose your health information in connection with this study. You have the
right not to give us this permission, in which case you will not be able to participate in this study. If you
do not give this permission, your treatment outside of this study, payment for your health care, and your
health care benefits will not be affected.
What information about me may be used or shared with others?
The following information may be used or shared in connection with this research:
[Edit the following as applicable: add or delete items as appropriate to your specific research protocol]
 Information in your medical record and research record, for example, results from your physical
examinations, laboratory tests, procedures, questionnaires and diaries.
[Note: Genetic testing, HIV results, substance abuse treatment and mental health records may require
different consents or language under applicable law.]
You have a right to access information in your medical record. In some cases when necessary to protect
the integrity of the research, you will not be allowed to see or copy certain information relating to the
study while the study is in progress, but you will have the right to see and copy the information once the
study is over in accordance with NYU Langone Medical Center policies and applicable law.
Why is my information being used?
Your health information will be used by the research team and others involved in the study to conduct
and oversee the study.
Who may use and share information about me?
The following individuals may use, share or receive your information for this research study:
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The Principal Investigator, study coordinators, other members of the research team, and
personnel responsible for the support or oversight of the study.
The study sponsor: [specify name(s) of study sponsors. Delete this item if an NYULMC
department is the only study sponsor]
Governmental agencies responsible for research oversight (e.g., the Food and Drug
Administration or FDA).
Health care providers who provide services to you in connection with this study, and laboratories
or other individuals who analyze your health information in connection with this study.
Other study sites
[Specify other non-NYU persons/entities as applicable, for example:
– Contract research organizations
– Central research laboratories
– Study related committees/boards/centers (Data & Safety Monitoring Board, Endpoint
Committees, Clinical or Data Coordination Centers, etc.)
Your information may be re-disclosed or used for other purposes if the person who receives your
information is not required by law to protect the privacy of the information.
How long may my information be used or shared?
Your permission to use or share your personal health information for this study will never expire unless
you withdraw it.
Can I change my mind and withdraw permission to use or share my information?
Yes, you may withdraw or take back your permission to use and share your health information at any
time. If you withdraw your permission, we will not be able to take back information that has already been
used or shared with others. To withdraw your permission, send a written notice to the principal
investigator for the study noted at the top of page 1 of this form. If you withdraw your permission, you will
not be able to stay in this study.
14. Optional permission for future use
NYULMC would also like to store, use, and share your health information from this study in research
databases or registries for future research conducted by NYULMC or its research partners. Such health
information may include biological samples from the study. To give this additional permission, check the
box below and write your initials where indicated. You may still participate in this study even if you do
not give us this additional permission.
NYULMC will continue to protect the confidentiality and privacy of this information as required by law and
our institutional polices. If you give this additional permission, you will continue to have the rights
described in this form. You have the right to take back this additional permission at any time.
Checking this box indicates my permission to store, use, and share my health
information from this study in research databases or registries for future
research conducted by NYULMC or its research partners.
Subject Initials
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15. The Institutional Review Board (IRB) and how it protects you
The IRB reviews all human research studies – including this study. The IRB follows Federal Government
rules and guidelines designed to protect the rights and welfare of the people taking part in the research
studies. The IRB also reviews research to make sure the risks for all studies are as small as possible.
The NYU IRB Office number is (212) 263-4110. The NYU School of Medicine’s IRB is made up of:
 Doctors, nurses, non-scientists, and people from the Community
16. Who can I call with questions, or if I’m concerned about my rights as a
research subject?
If you have questions, concerns or complaints regarding your participation in this research study or if you
have any questions about your rights as a research subject, you should speak with the Principal
Investigator listed on top of the page 1 of this consent form. If a member of the research team cannot be
reached or you want to talk to someone other than those working on the study, you may contact the
Institutional Review Board (IRB) at (212) 263-4110.
[Add this paragraphs for studies requiring registration with ClinicalTrial.gov:]
A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by U.S.
Law. This Web site will not include information that can identify you. At most, the Web site will include a
summary of the results. You can search this website site at any time.
When you sign this form, you are agreeing to take part in this research study as described to you. This
means that you have read the consent form, your questions have been answered, and you have decided
to volunteer.
Name of Subject (Print)
Signature of Subject
Date
Name of Person Obtaining Consent (Print)
Signature of Person Obtaining Consent
Date
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[The following sections provide signature blocks necessary for other types of research including:
 Studies where it is necessary to use an authorized subject representative
 Pediatrics studies – for parental consent
 Studies using the short form consent process
 Studies involving subjects who cannot read
Select or delete a given section and it’s signature block as applicable for your specific study.]
[For studies using authorized subject representatives:
Use the authorization signature line only for studies that are approved by the IRB to permit subject
representatives to authorize a subject’s participation in research. Delete if not applicable.]
For subjects unable to give consent, the consent for study participation and authorization to collect and
use protected health information is given by the following authorized subject representative:
Name of Authorized Subject Representative (Print)
Signature of Authorized Subject Representative
Date
Select the category that best describes the above Authorized Subject Representative:
Court-appointed guardian
Health care proxy
Durable power of attorney
Family member/next of kin; for this category describe relationship below:
[For pediatric studies (note: certain studies require the signature of both parents. If the IRB determines
this is required, add another signature block for the other parent.)]
Signature of Parent(s)/Guardian for Child
I give my consent for my child to take part in this research study and agree to allow his/her health
information to be used and shared as described above.
Name of Parent (Print)
Signature of Parent
Date
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[For studies using the short form consent process:]
Witness to Consent of Non-English Speaking Subjects Using the “Short Form” in Subject’s
Spoken Language
Statement of Witness
As someone who understands both English and the language spoken by the subject, I represent that the
English version of the consent form was presented orally to the subject in the subject’s own language,
and that the subject was given the opportunity to ask questions.
Name of Witness (Print)
Signature of Witness
Date
[For studies involving subjects who cannot read:]
Witness to Consent of a Subject Who Cannot Read or Write
Statement of Witness
I represent that the consent form was presented orally to the subject in the subject’s own language, that
the subject was given the opportunity to ask questions, and that the subject has indicated his/her
consent and authorization for participation by (check box that applies).
Subject making his/her own “X” above in the subject signature line
Subject showed approval for participation in another way; describe:
Name of Witness (Print)
Signature of Witness
Date